Disease Management Programme Module On Heart Failure: Current Guidelines Indicate Some Need For Revision

On 14 February 2012, the German Institute for Quality and Efficiency in Health Care (IQWiG) published the results of a literature search for evidence-based clinical practice guidelines on the treatment of people with heart failure. The aim of the report is to identify those recommendations from current guidelines of high methodological quality that may be relevant for the planned revision of the module “heart failure” in the disease management programme (DMP) for coronary heart disease (CHD). According to the results of the report, there is no compelling need for revision of any part of the DMP module. However, IQWiG identified several aspects that could be supplemented and specified.

Evidence was documented in detail

One of the responsibilities of IQWiG specified by law (Social Code Book V, SGB V) is to develop and issue recommendations for DMPs. It is first of all the Institute’s aim to identify differences between guideline recommendations and the DMP. The Federal Joint Committee (G-BA) then examines these differences and decides on whether they should actually lead to a revision of the DMP.

In the commission now completed, which was awarded by the G-BA, IQWiG systematically searched for new guidelines, assessed their methodological quality, and extracted relevant recommendations on the diagnosis and treatment of heart failure. In addition, the Institute documented how highly the guideline authors graded the robustness of the recommendations. However, the sources of the recommendations were not examined again; this is where IQWiG’s guideline appraisals and benefit assessments differ.

No contradictions between the DMP and current recommendations

A total of 27 German and international guidelines containing recommendations on the treatment of people with heart failure were included. As the analysis showed, the recommendations are, by and large, consistent with the specifications of the DMP. No contradictions in content concerning the DMP requirements were found. The Director of IQWiG, Professor Dr med. Jürgen Windeler, stresses that “patients with heart failure can thus be sure that the current DMP is consistent with the current status of medical knowledge on all main points.”

Diabetes and sleep apnoea not considered so far

However, in these guidelines, additional recommendations were found on several subject areas which, after examination and discussion, could be supplemented or described in more detail in the DMP module.

The aspects so far missing in the DMP module but mentioned in several guidelines with a high grade of recommendation include the use of pacemakers and cardiac resynchronisation therapy (CRT) in patients with atrial fibrillation, as well as electrical cardioversion, flu vaccination, sexual counselling, and care of older patients. In addition, guidelines recommend the treatment of accompanying diseases such as diabetes mellitus and sleep apnoea in patients with heart failure. Topics already considered in the DMP module, but described in more detail in current guidelines include the treatment of patients with hypertension, for whom the guidelines contain additional recommendations.

Procedure of report production

IQWiG published the preliminary results in the form of the preliminary report in March 2011 and interested parties were invited to submit comments. When the commenting procedure ended, the preliminary report was revised and sent as a final report to the contracting agency, the Federal Joint Committee, in December 2011. The written comments are published in a separate document at the same time as the final report. The report was produced in collaboration with external experts.